Pulmonary Toilet Lexicon

Bronchial Pulmonary Hygeine: Use of a variety of procedures and medicines to try to help the patient expectorate thick secretions, or to help losen secretions from the bronchioles to the upper airways so the patient can more easily spit it up.  The goal is enhance secretion clearance to help prevent lung infections, enhance ventilation, improve pulmonary function and gas exchange.

Expectorate:  To spit up

Pulmonary Toilet: It's a generic term to describe any effort, medicinal or other, to help loosen or break up thick secretions that are causing respiratory distress, to help bring secretions to the upper airway so they can be either swallowed or expectorated.  The most common therapies here are albuterol and mucomyst nebulizer treatments, followed by either use of flutter valve or postural drainage and chest percussion.

Who needs it?  The patient feels like they have something to cough up, but are unable to generate enough flow to expectorate it.  Rhonchi is a common lung sound heard upon auscultation.

What are Indications for Pulmonary hygiene or toilet?

• Thick secretions (may be heard in large airways by auscultation (rhonchi)
• Retention of secretions
• Difficulty clearing the airway (trouble getting phlegm up)
• Artificial airways (intubation or tracheotomy)
• Atelectasis caused by mucus plug or obstruction
• Conditions that increase amount and thickness of secretions (COPD, Cystic fibrosis, asthma)

Rhonchi.  This is the sound of air moving through large airways.  It is commonly described as coarse. Sometimes it is mistaken for a wheeze, especially as it resonates throughout the lung fields. Sometimes it may present as a forced, expiratory wheeze, and may even be audible.

What does the pulmonary toilet involve? 

Bronchodilator.  Inhaling this medicine will help to open up air passages, releasing trapped secretions so they may be expectorated.  The most common medicine is albuterol, although  xopenex may also be prescribed.

Mucolytic: Inhaling these medicines will help to break up secretions so they may be expectorated.  It makes phlegm more liquid and easier to spit up. This medicine may cause bronchospasm, so it should always be given with a bronchodilator. The most common medicine used in the hospital setting is Mucomyst (acetylcysteine). Pulmoyme (dornase alfa) is commonly prescribed for cystic fibrosis patients.  Other mucolytics may include ambroxel, carbocisteine, and erdosteine.

Chest physiotherapy (CPT): This describes the various techniques a therapist might use in order to help knock thick secretions loose so they may be more easily expectorated.  Procedures may include chest percussion, mechanical percussors, postural drainage, PEP valves, and flutter valves.  Ideally, CPD should be performed prior to meals, or 60-90 minutes after meals.  If the patient is on pain management, it should be performed 30-60 minutes after pain medicines are given.

Chest Percussion: A therapist uses cupped hands and applies rythmic clapping on a patient's chest in order to break up secretions so they can be more easily expectorated.  It may be performed over the entire chest, although is more commonly performed only over the infected area.

Vibration: This is where you put one hand over the other over the infected area and generate vibrations during expiration to help loosen secretions. This is generally done after percussion, and particularly for patients with thick and copious secretions.

Mechanical Percussor

Mechanical Percussor:  Due to the trauma that may be caused by CPT, mechanical percussors are thought to accomplish the same goal as CPT. Constant vibrations from the device are thought to break up thick secretions so they may be more easily expectorated.

Postural Drainage.  This is using gravity to aid in draining secretions from various areas of the lungs.

• Postural drainage and CPT or mechanical percussors are often used in tandem to enhance secretion removal
• Ideally, the infected side should be up to allow gravity to enhance movement of secretions to trachea to enhance removal.  
• After postural drainage is complete, the infected side should be down so that secretions do not drain into good areas of the lungs to make breathing more difficult.  If a patient's SpO2 suddenly drops, this is something that might be considered.  
• To learn more check out the AARC Clinical Practice Guidelines. 

Positive Expiratory Pressure (PEP) valves:  These are small, hand-held devices that a patient exhales into.  A positive pressure is thought to enhance secretion production and prevent and treat atelectasis.

Flutter Valves:  The most common one is referred to as an Accapella Flutter Valve.  It combines PEP therapy with gentle vibrations.  The small, hand-held device consists of a mouthpiece connected to a cylinder in which a stainless steel ball rests in a cone shaped valve. The patient exhales through the cylinder and causes the ball to move up and down during the exhalation. The effect is threefold

1. Vibrate the airways to facilitate movement of mucus
2. Increase endobronchial pressure to avoid air trapping
3. Accelerate expiratory airflow to facilitate the upward movement of mucus.

Many hospitals are now using these instead of the more invasive chest percussion and postural drainage. Although, sometimes a combination of the two are used.  Just about any alert patient can do this regardless of lung capacity. It takes about half the time of CPT and postural drainage.

Suction: This involves using negative pressure to suck secretions from the airway.  

• Upper Airway:  A common device for suctioning the upper airway is a Yankaur. It helps facilitate secretion removal of upper airway, and is similar to devices used in dentist offices.  
• Lower Airway.  Various suction catheters may be inserted through the mouth, or one of the nostrils, into the large airway (usually to just above the corina).  Negative pressure helps suck secretions blocking the airways.  This is generally referred to as deep tracheal suctioning. It should rarely be performed on an awake and alert patient.  It is most commonly performed on a patient who is intubated.  
• Suction pressure: This is usually determined as follows:
• Adults = -100 to -120 Hg
• Children = -80 to -100 Hg
• Infants = -60 to -80 Hg
• Catheter Size: A common formula for choosing the ideal suction catheter for a patient who is intubated:
• Double the internal diameter (ID) of the endotracheal tube (ETT) and multiply by 2, then use the next smallest catheter size. For example, if the patient has a size 8 ID ETT, 8*2=16 or a size 14 suction catheter.

Yankaur: As noted above, this is a device that fits into the patient's mouth, and can be used to suction secretions in the mouth to the back of their throat. This is generally considered to be non-invasive.

Deep tracheal suction: As noted above, this involves inserting a catheter beyond the trachea to just above the corina.  Ideally, a catheter should never touch the corina in order to prevent trauma.  Also, this procedure should never be performed on a non-intubated patient who is awake and alert, as it is considered extremely traumatic.  It should be performed as needed on intubated and trached patients in order to clear the airways of secretions.  It's ideal for generating a sterile sputum sample for analysis.

Closes suction system: The most common one used is called a Ballard. This is used on intubated patients so you don't have to break the circuit to suction the airway. This prevents loss of PEEP and reduces risk of Ventilator Acquired Pneumonia.

Incentive Spirometer:   During normal breathing, people sigh 3-5 times per hour.  This is a natural mechanism to clear secretions from airway to prevent pneumonia and alveolar recruitment to prevent atelectasis.  This natural mechanism is blunted due to pain from abdominal or chest operations.  It is also blunted due to pain medicine.  Ten inhalations per hour using an incentive spirometer is meant to encourage secretion removal and alveolar recruitment.  Volume spirometers provide some resistance to inhalation, and allow therapists to monitor a patient's progress. It is usually followed by cough and deep breathing exercises.

Cough and deep breathing exercises: A patient should be encouraged to take in a deep breath to fill the lungs with air, and then to cough.  This is yet another means of enhancing secretion clearance and alveolar recruitment.

Abdominal Thrust: This is performed only on quadraplegic patients. This is where you push in and up on the abdomin to force up the diaphragn to facilitate a cough. You'll need to do this in sync with the patient.  I find that the best teachers of this procedure are the patients themselves.

Mechanical Insufflation-Exsufflation: It's a machine that alternates positive and negative pressure to the airway to help increase expiratory flows and remove secretions. It's a non-invasive procedure that can be performed with a mouthpiece or mask for spontaneously breathing patients, or with an adapter to an artificial airway. It's usually used with patients with neuromuscular disorders.

When should pulmonary hygiene be discontinued?

• Improvement in chest x-ray
• Improved vital signs
• Improved oxygenation (monitored by pulse oximetry or ABG)
• Less demand for oxygen (less supplemental oxygen required, lower FiO2s)
• Sputum production (patient coughing up sputum without assistance)
• Auscultation (improved lung sounds)
• The patient can generate an effective spontaneous cough

Originally published on 5/20/09 on respiratorytherapycave.blogspot.com; Edited and updated for accuracy by Rick Frea

My answers to your RT queries

Every week I check my statcounter to see who's typing things into Google or Yahoo and being linked to my RT Cave blog. Assuming the queries were not answered, I provide in this spot each week my humble responses.

And, hey, if the query is comical, it deserves a comical response. If it's serious, I treat it as serious. That in mind, here are this weeks queries:

1. career change respiratory therapist to rn : While I think that RT is a noble profession just like RN, we RTs are still working on developing the same kind of respect RNs have in the medical profession. We have made major strides just in the 10 years I've been an RT. But we have much farther to go. That in mind, there are some struggles in the RT community. Likewise, pay is not as great as for RNs. Fair? Well, if you don't think so, you can always become an RN yourself. Still, can you go from a mucus sucker, frivolous Scrubblin-Bubblin giver, roamer of the entire hospital to a poop scooper person who has to take care of the same patient all night. For the advantages and disadvantages of being an RT, click here.

2. how to break up wet lungs: Despite the myth that aerosolized sulfate will bind to the fluid particles in the lungs forcing the body to "exhale" the fluid, this IS -- my friends -- just a myth. Actually, if you have a patient with wet lungs, a diuretic is the best method of getting fluid from the lungs to the Kidneys and out of the body through the urinary tract. For more information about diuretics, click here. If by "break up" you are referring to pneumonia, the only thing that will "break up" pneumonia is the human body's defense system, and sometimes with a little assistance of an antibiotic.

3. what is the indication for albuterol with atrovent? It's basically the preference of the doctor. Some studies do indicate slight improvements when Atrovent is used in conjunction with Albuterol in emergency rooms. Others show that it works well for COPD to improve lung function long term (click here for more). Most studies show Atrovent is not beneficial for asthma patients. Whether they want to believe every study that's out there is up to the discretion of each individual doctor. Out of the hospital Atrovent is no longer used as a rescue bronchodilator. It is used as a "preventative" asthma medication. For more information about Atrovent as a bronchodilator click here and here.

4. coarse lung sounds: There is no such thing as coarse lung sounds. If you are hearing coarse, then what you are really hearing is rhonchi. Click here for more information.

5. dont give incentive spirometer to copd patietns: This is a fallacy. There is no reason a COPD patient couldn't benefit from good old fashioned deep breath with a breath hold followed by a cough. In fact, I would recommend it.

6. will unprescribed ventolin hurt children? Not any more than prescribed Ventolin, unless it was obtained by some illegal source; or unless it is outdated. Still, if you decide to use some other person's prescription, you should at the very least call your or your child's doctor.

7. baby's chest caves in while crying: This could be a sign of respiratory distress. Click here and check the other signs of respiratory distress.

8. atrovent pulmonary oedema: I have not seen any studies that show Atrovent does anything for pulmonary edema. If you find any studies to the contrary I would love to read about it.

9. when to stop singulair for asthmatics: Of course I'm no doctor, but I think the general consensus is you do not ever stop taking medications that are preventative in nature unless some better and safer med comes along, OR if you experience side effects that effect your quality of life. Singulair is a medication that works to prevent you from responding to your allergens, and there fore if you stop taking it you could have trouble with allergies and asthma. Asthma medicine should never be stopped without the explicit direction of a physician.

10. dummies guide to respiratory care: Sometimes that's how I think of this blog. However, none of my readers are dummies. You are all brilliant.

Pneumonia: Here's how you can prevent it

As I wrote in yesterdays post, over 3 million people are diagnosed with pneumonia each year, 500,000 require admission to the hospital.

A question I get often from my patients is: "What can I do to prevent myself from getting pneumonia?"

To get a good overall idea of what pneumonia is, and who exactly is at risk, you should check out the post I wrote yesterday, which I will link to here.

Every person, particularly the elderly (over age 65) and/or chronically ill, should keep pneumonia in the back of their mind, because chances are they are at a high risk of getting it. There are a few simple things you guys can do to reduce the risk of getting pneumonia.

Keep in mind, however, that there are no guarantees.

The simplest thing you can do is wash your hands. There is no more effective thing you can do to prevent the transfer of viruses and bacterias than by simply washing your hands often.

Another simple thing you can do is get the pneumonia vaccine offered to you by your doctor. Currently, there are vaccines available for pneumonias caused by pneumococcal pneumonia, Haemophilus influenzae, and influenza virus.

Respiratory-lung-healthcare.net reports that the vaccines are about 80% effective in young adults, but not so effective in those who are at high risk. Likewise, not all pneumonias have a vaccine. Needless to say, that's no revelation there. Many patients who have been diagnosed with pneumonia also say they received the vaccine.

Thus, we obviously cannot rely just on the vaccine to prevent pneumonia.

So, besides vaccines, the best therapies to prevent pneumonia is cough and deep breathing exercises (with a good 3-6 second breath hold), and exercise, even a simple walk around the room can be effective enough to prevent pneumonia.

At our hospital, doctors order all patients at high risk for pneumonia to be provided and instructed on the use of an Incentive Spirometer (IS). It is their belief that any patient can do an IS, and that it's equally effective in preventing pneumonia in all patients. However, that is not always the case in the ideal world.

That in mind, here is the long version of what I tell my patients:

"Many years ago pneumonia was very prevalent in hospitals. Many post-op patients were getting pneumonia, and many of them were dying. Familiar with these statistics, some wise person decided that they were developing pneumonia because they weren't taking in deep breaths.

"Normal healthy people take in three or four sighs every hour. This is the bodies natural mechanism for exercising the parts of the lungs that are not used during normal respiration's.

"However, when you become debilitated in one way or another, you are elderly, weak, sore from breaking your ribs, sore because you had surgery on your chest or abdomen and don't want to take in a deep breath, you have Lou Gehrig's disease, are paralyzed, or something else that diminishes your ability to move or take deep breaths, then you are susceptible to getting pneumonia.

"What you need to do is to concentrate on your breathing, something most people take for granted. While you are home, after eating breakfast, you should concentrate on taking deep breaths. In fact, you should do this once every hour or two. And then you should force yourself to cough.

"You take in a slow deep breath through your nose, hold your breath for three to five seconds, and then you exhale slowly. You should do this five to ten times, and then cough. This whole process helps you to recruit and fill with air any collapsed alveoli that are susceptible to pneumonia, expectorate secretions, and exercise your lungs.

"In the hospital, we encourage those at high risk for pneumonia to not only do this, but we use what we call an incentive spirometer. But, in essence, an incentive spirometer is no more effective for preventing pneumonia than a good cough and deep breathing session with breath hold."

Of course, here is where I show them how to use the IS. Most patients do well with the IS, however, some patients just can't seem to get the hang of it. For these patients, I revert them back to the simple cough and deep breathing exercises.

I have never found a patient not be able to do effective cough and deep breathing exercises, even most dementia and Alzheimer's patients do well with this.

Some RTs and RN, in my humble opinion, get so wrapped up in the idea that the IS must be used to prevent pneumonia, that they focus all their energy on having the patient use it, even though the patient is not using it correctly, or, more than likely, is simply unable to comprehend how to use it.

On these patients, I say, "Forget the IS."

This is just something to keep in mind.

Now, our RT bosses might be mad at me for telling you how to prevent pneumonia, because they want you to get sick so they can make money off you, but not me; I want you guys to be educated on the best means of avoiding the need for our services.

The other thing to keep in mind is that your body is not used to being immobile. If you're not moving around, you open the door for a variety of complications, pneumonia being one of them.

This is why, even after you have a major abdominal or chest surgery, your nurse will have you walking the halls, regardless of your level of pain. You might get some good drugs to help with the pain, such as Morphine, but doing this may still be a challenge.

We here at the RT Cave, when teaching the IS or cough and deep breathing exercisers, encourage our patients to push themselves to that pain threshold. It may be agonizing now, but it will allow you to get out of the hospital quicker, which will not be the case if you get pneumonia.

Immobile hospital patients will be taken care of by qualified RTs and RNs who know the best techniques of preventing pneumonia. For people living at home who are at high risk, it's your job to educate yourself, and that's the purpose of this post.

If you want an incentive spirometer, you'll have to refer to your doctor. If you want to know how to use an incentive spirometer, click here. For a boring but effective video on how to use an IS, click here.

Still, nothing is more effective than simple cough and deep breathing and breath hold exercises to eliminate your odds of getting pneumonia. You healthy people don't have to think about your breathing, but anyone at high risk must and should.

That concludes today's class.